INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on November 21-22, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, The Healing Way was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Ten client records were reviewed on November 21-22, 2019. The facility failed to document a comprehensive treatment plan in client records, #2 and 4.
Client #2 was admitted on 10/2/19 and is currently an active client. An initial treatment plan was documented on 10/2/19. The Comprehensive treatment plan was due to be completed by 11/2/19 but was not documented at the time of the investigation.
Client #4 was admitted on 10/3/19 and was discharged on 11/7/19. An initial treatment plan was documented on 10/3/19. The Comprehensive treatment plan was due to be completed by 10/10/19 but was not documented at the time of the investigation.
|
Plan of Correction
The following plan of action has been addressed, staff has been trained on developing individual treatment planning and comprehensive treatment planning as of 11/25/2019. Additionally, charts reviews are being conducted by The Healing Way Lead Clinician and Clinical Supervisor during weekly supervision. The Clinical Director will randomly monitor chart reviews to ensure accuracy of treatment planning documentation.
As of (11/26/2019) Therapists have been trained on 30 day initial treatment plans and 60-day comprehensive treatment planning. The Lead Clinician will conduct chart monitoring on a weekly basis during group supervision to ensure compliance of initial (30day) and 60 day comprehensive treatment planning. At clinical contact Therapist and Client #2 collaboratively completed the comprehensive treatment plan and signed. Client 4 has been discharged as of 11/7/2019, no treatment plan was able to be updated.
The Clinical Director has developed an audit form to be completed by all therapist to ensure accurate completion of all clinical forms and treatment documentation as of 11/25/2019.
During clinical contact client #2 and Therapist completed and signed comprehensive treatment plan. All Therapist was provided in-housing training on 11/25/2019 to ensure compliance with Initial and Comprehensive treatment planning to ensure completion and accuracy.
Weekly clinical chart audits are completed by Clinical Supervisor during individual and group supervisions.
The Clinical Director is responsible for completing a plan of correction for any discrepancies found during monthly clinical chart audits.
Client #4 has been discharged as of 11/7/2019. All Therapist have been in-house trained on treatment updating plan.
The Clinical Director has developed an audit form to assist all Therapist with compliance in accurately updating comprehensive treatment planning as of 11/25/2019. See attachment
|
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Ten client records were reviewed on November 21-22, 2019. The facility failed to document a treatment plan update in client record, #8.
Client #8 was admitted on 7/25/19 and is currently an active client. A comprehensive treatment plan was documented on 7/30/19; a treatment plan update was due to be completed by 9/30/19 but was not documented at the time of the investigation.
|
Plan of Correction
Therapists were trained on time management to ensure accurate completion of treatment planning. As of 11/25/2019 all Therapist have been provided an audit form to assist with monitoring 30 day initial treatment planning and 60 day comprehensive treatment planning documentation.
During group supervision charts will be randomly monitor by The Lead Clinician and Clinical Supervisor. Additionally, the Clinical Director will periodically monitor client charts to ensure compliance in initial treatment planning and comprehensive treatment planning documentation.
Therapists were trained on time management to ensure accurate completion of treatment planning. As of 11/25/2019 all Therapist have been provided an audit form to assist with monitoring 30 day initial treatment planning and 60 day comprehensive treatment planning documentation.
During group supervision charts will be randomly monitor by The Lead Clinician and Clinical Supervisor. Additionally, the Clinical Director will periodically monitor client charts to ensure compliance in initial treatment planning and comprehensive treatment planning documentation.
Client #8 treatment plan has been located in file room and has been added to client's active chart. All Therapist have been provided in-house training on the importance of filing clinical documentation.
|
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
|
Observations
Ten client records were reviewed on November 21-22, 2019. The facility failed to document a complete client record for clients #1, 4 and 5.
Client #1 was admitted on 10/29/19 and is currently an active client. There was a consent to treatment in the record but it had not been completed or signed by the client.
Client #4 was admitted on 10/3/19 and was discharged on 11/7/19. There was a discharge ASAM form dated 11/7/19 however there was no discharge summary form the facility documented at the time of the investigation.
Client #5 was admitted on 10/21/19 and was discharged on 11/5/19. The record of service indicated that the client participated in both a group and individual session on 10/28/19 however there were no progress notes documented for these sessions.
|
Plan of Correction
Therapist's was retrained on accurate completion of all required documentation policies and procedure which will be reviewed periodically by Clinical Supervisor to ensure accuracy consent of treatment.
As of 11/26/2019 the Clinical Supervisor formulated a newly developed consent form to treatment which was updated and signed in Client #1 active chart.
All active client charts have been updated with newly revised consent to treatment. Staff will place revised consent to treatment forms in all developed charts who are admitted into treatment and will be updated on a yearly basis to remain within compliance.
Client #4 has been discharge as of 11/7/2019 discharge summary has been completed as of 11/28/2019.
Staff has been provided in-house training on the completion of discharge summary during group supervision on 12/5/2019. Additionally, monthly charts reviews are conducted by The Healing Way Clinical Supervisor to ensure compliance in clinical documentation. Clinical Director has provided all staff with audit form to assist with remaining compliant with chart compliance as of 11/26/2019. Audit form has been provided see attachment.
Client #5 group and individual notes have been placed in client's chart. All Therapist has been provided in-house training on timely submission of Clinical DAP notes. Clinical DAP notes are to be completed within 24 hour after service render. Lead Clinician and Clinical Supervisor will ensure that all DAP notes are completed within required 24 hour time frame by providing Clinical Supervisor productivity audit form with copies of services render and proof of written DAP note. Staff has been provided in-house training on 12/5/2019 submission of group and individual DAP note.
Client 5# DAP note was locate in file room to be placed in chart. All staff was provided in-house training on accurate submission of Clinical documentation. Lead Clinician will monitor charts periodically to ensure accuracy of DAP note submission.
|